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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200285
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:53:22 PM

Document Has Been Signed on 07/11/2024 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VIA CENTERFACILITY NUMBER:
079200285
ADMINISTRATOR/
DIRECTOR:		MCGEE, ANGELAFACILITY TYPE:
735
ADDRESS:133 HEATHER DRIVETELEPHONE:
(415) 613-9372
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 5DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:DAWLT SEVOUM, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 7/11/202 at 09:45am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Dawlt Sevoum, Caregiver and explained the purpose of the visit. Caregiver Debelo Fufa arrived at 10:30am, House Manager, Deberitu Mekonnen, arrived at 11:20am. Administrator certificate #6006628735 expires 11/24/2023. Facility's fire clearance is for six (6) ambulatory and one (1) non-ambulatory client.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of four (4) total bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 95.1 degrees Fahrenheit. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 10/1/2023. Fire extinguisher was last services on 1/09/2024. Last fire drill conducted 3/26/2024. First aid kit was observed to be complete.

Continued on LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VIA CENTER
FACILITY NUMBER: 079200285
VISIT DATE: 07/11/2024
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Continued from LIC809.

LPA reviewed four (4) client records and none contained an appraisal needs and services plan. LPA reviewed four (4) staff files and two (2) missing health screenings and two (2) were complete..

LPA observed the following deficiencies:
  • At 10:40am, LPA observed bathtub needs repair and is stained, bathroom #2 has a broken toilet seat and bathtub stained, kitchen table unstable, rocking chair has rips, dishwasher not operating.
  • At 10:55 LPA observed water temperature was 95.1.


LPA requested the following documents to be submitted to CCLD by 7/18/2024.
  • Client roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan (9 pages)
  • Surety Bond
  • Liability insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeals rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 01:53 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/11/2024 at 01:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VIA CENTER
FACILITY NUMBER: 079200285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having bathtub needs repair and is stained, bathroom #2 has a broken toilet seat and bathtub stained, kitchen table unstable, rocking chair has rips, dishwasher not operating which poses a potential health and safety risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Administrator agreed to have repairs made to the dishwasher and bathtub, toilet seat and have bathtubs stains removed, repair or remove chair with rips, have kitchen table repaired or replaced and submit photo to the department by the POC date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the water temperature 95.1 which posed a potential health and safety risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Administrator agreed to keep the water temperature maintained between 105 and 120 degrees. DEFICIENCY CLEARED DURING VISIT.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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